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Peds Chest and Abdomen Flashcards

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1
Q

Meconium Aspiration

A

Term babies

Hyperinflation (ball-valve –> air trapping)

Coarse, Reticular, Ropy asymmetric perihilar opacities

NO AIR BRONCHOGRAMS

Risk of PTX

Mortality from severe CLD and Pulm HTN

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2
Q

RDS/Hyaline Membrane Disease

A

Premature

Surfactant Deficiency –> lung collapse

HYPOinflation

Bilateral GRANULAR opacities

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3
Q

TTN

A

Coarse Interstitial markings

Fluid in fissure

+/- Small Pleural Effusions

Normal to HYPERexpanded lungs

Starts at 6h, peaks at 1 day, resolved by 3 days

Seen in:

C-sections, sedated moms, & with DM

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4
Q

PIE

A

Pulmonary Interstitial Emphysema

Patient on Vent- air dissects out of alveoli into interstitium

Risk of PTX

Can progress to large cystic masses/bullae –> amss effect on mediastinum

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5
Q

PIE Treatment

A

Place Affected side Down

Change Vent settings- oscillating/high frequency

  • lower TV
  • higher RR
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6
Q

Bronchopulmonary Dysplasia

A

Chronic Lung disease (BPD)

Premature, tiny babies

Too long on Vent

2 weeks of Vent –> hazy lungs –> coarse opacities after a few months –> *bubble-like lucencies* or *Band-like opacities*

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7
Q

Sequestration

A

NO CONNECTION TO BRONCHIAL TREE or PAs

Blood supply from branch off aorta

Intra or Extra Lobar

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8
Q

INTRA-lobar Sequestration

A

Recurrent Pna’s in adolescents/young adults

Usually LLL (2/3) or RLL (1/3)

Does NOT have own Pleura

Drains via Pulm Vein into Left Atrium

No associated Devo Abn’s

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9
Q

EXTRA-lobar Sequestration

A

Presents in infancy

90% in LLL

10% Subdiaphragmatic

Drains via SYSTEMIC veins into Rt Atrium (via IVC or azygos)

Feeding artery can come from outside (i.e. below diaphragm)

Has EXTRA stuff

  • Pleura
  • Associated Developmental Abns
    • Cardiac Abns
    • CCAM aka CPAM
    • CDH and/or Pulm Hypoplasia
    • Vertebral Anomalies
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10
Q

CCAM aka CPAM

A

Congenital Pulmonary Airway Malformation

OR

Congenital Cystic Adenomatoid Malformation

  • Affects ONE lobe (any lobe)
  • Communicates with Airway (unlike Sequestration)
    • Air trapping 2/2 ball valve because adenomatoid tissue is in airways
  • NOT supplied by systemic artery (that is a Sequestration)
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11
Q

CPAM Types

A

Type 1

  • Most common
  • large cysts, 1 or more (1-10 mm)
  • malignancy risk

Type 2

  • Small cysts, multiple (0.5-1.5 mm)

Type 3

  • Microcysts, numerous (appears solid)
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12
Q

Congenital Lobar Emphysema (CLE)

A

Progressive Overinflation 2/2 Air trapping (more and more lucent lung over time)

Affects LUL (40%)

Also RML and RUL can be affected

Associated with Aberrant Left PA (pulm sling)

Assoc with Congenital Heart Defects (VSD, PDA, TOF)

Tx - Lobectomy

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13
Q

Swyer James Syndrome

A

Unilateral Lucent Hemithorax

2/2 Post infectious obliterative bronchiolitis (adenovirus or Mycoplasma) in infancy/young child

Looks like CLE but with Hx of infection

Affected lung tends to be smaller than the other

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14
Q

Neuroblastoma Locations

A

Adrenal Gland most common

Extra-adrenal RP

Posterior mediastinum/paravertebral symp chain (most common posterior mediastinal mass in kids under 2 yo)

Neck and Pelvis are least common

Likes to grow into neural foramina

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15
Q

Neuroblastoma Mets

A

Liver and Bone

Posterior mediastinal mass can involve ribs and vertebral bodies

Stage 4S = NB with mets confined to liver, skin, and bone marrow in a patient under 1 yo- better prognosis

If over 1 yo - just stage 4

If mets anywhere else in a child under 1 yo –> stage 4

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16
Q

Neuroblastoma Characteristic Feature

A

Calcifications!

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17
Q

Pepper Syndrome

A

Neuroblastoma with hepatomegaly 2/2 innumerable liver mets

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18
Q

Hutchinson Syndrome

A

Neuroblastoma with skeletal mets - particularly skull resulting in PROPTOSIS

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19
Q

Blueberry Muffin Syndrome

A

Neuroblastoma wth multiple skin mets (blue subQ nodules)

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20
Q

Opsoclonus Myoclonus Syndrome

A

Dancing eyes and feet related to inflammatpry/autoimmune Neuro d/o

Often paraneoplastic - strong assoc with Neuroblastoma

Dancing eyes, myoclonic jerks, cerebellar ataxia

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21
Q

Askin Tumor

A

PNET of the Chest Wall

Part of Ewing Sarcoma Spectrum

Heterogeneous with enhancing solid portions

Displaces structures then when it gets big – eats up rib

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22
Q

Pediatric Large Posterior Mediastinal Mass DDx

A
  • Over age 10
    • PNET/Ewing’s (with eaten up rib) - malignant
    • Ganglioneuroma (round)- benign
    • NFs - benign
    • Neurenteric cyst- benign
    • Extramedullary hematopoiesis- benign
  • Under age 10 - Neuroblastoma
  • Under age 2 - Pleuropulmonary blastoma
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23
Q

Neurenteric Cyst

A

Posterior mediastinum

No commonucation with CSF

Fluid attenuation

Assoc. with Vertebral Anomalies

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24
Q

VACTERL

A

Vertebral Anomalies

Anus (imperforate)

Cardiac

Tracheo - Esophageal fistula

Renal

Limb

Heart and kidneys most affected

If both limbs –> usually BOTH kidneys too

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25
CHARGE
**C**oloboma (eye abnormality failure of choroidal fissure) **H**eart Defects **A**tresia (Choanal) **R**etardation **G**enital Hypoplasia **E**ar Abnormalities
26
Vascular Rings and Slings (list)
Double Aortic Arch R Aortic Arch w/ aberrant L Subclavian L Arch with Aberrant R Subclavian Anomalous L PA arising from the R PA (pulm sling) Innominate Artery Syndrome (controversial)
27
Double Aortic Arch Findings
Posterior Impression on esophagus Right arch is bigger than Left Presents early with Stridor Most common vascular ring- compresses trachea anteriorly, esophagus posteriorly
28
Branchial Arch defect causing Double Aortic Arch
Both left and right arches arise from LEVEL 4 Branchial arches
29
Findings of R Arch with Aberrant L Subclavian
Posterior impression on esophagus by Aberrant L Subclavian which courses R to L behind esophagus R arch indents trachea anteriorly/right Ring completed by Ligamentum Arteriosum
30
L arch and Aberrant R Subclavian Findings
NOT A RING OR A SLING **Posterior** impresson on ESOPHAGUS Dysphagia Lusoria NO STRIDOR Assoc with Diverticulum of Kommerell
31
Pulmonary Sling findings
ANTERIOR impression on ESOPHAGUS L PA is abberrant and arises from R PA L PA courses R --\> L BETWEEN Trachea and Esophagus Ligamentum arteriosum completes the ring
32
Innominate Artery Syndrome
Large thymus --\> Innominate artery presses anteriorly against trachea Controversial if actually causes breathing problems
33
Low Bowel Obstruction DDx | (neonates)
Long Microcolon 1. Meconium Ileus 2. Distal Ilial Atresia Caliber Change 1. Colonic atresia 2. Imperforate Anus 3. Meconium Plug Syndrome 4. Hirschsprung disease
34
High Bowel Obstruction DDx | (neonate)
Midgut volvulus/malrotation Duodenal atresia Duodenal web Jejunal atresia Annular pancreas
35
Duodenal Atresia
Double Bubble Sign No distal gas Cannulation error Associated with: Down syndrome Polyhydramnios
36
Double Bubble DDx
Congenital 1. Duodenal Atresia 2. Duodenal web 3. Annular pancreas 4. Midgut volvulus External 1. Choledochal or mesenteric cyst 2. Intramural duodenal hematoma 3. RP tumor 4. SMA syndrome
37
Triple Bubble Sign
Jejunal atresia 2/2 **vascular insult** in utero Multiple atresia = vascular error
38
Double bubble with distal gas
Duodenal Web/stenosis Annular pancreas Midgut volvulus
39
Meconium Ileus
Mostly CF patients Meconium obstructs at distal ileum Filling defects/obstruction on Fluoro Tx = enema
40
Meconium Plug Syndrome
aka "Small Left Colon" Transient functional obstruction Filling defects in **_transverse colon_** Tx = contrast enema **NOT ASSOC with CF** Seen if Mom had DM OR if Mom got MgSO4
41
Distal Ileal Atresia
Vascular insult in utero Contrast won't reflux into ileal loops. Tx = surgery
42
Currarino Triad
Anorectal malformation (imperforate anus) Sacrococcygeal agenesis/defect Presacral Mass (anterior meningocele or teratoma)
43
Imperforate Anus Associations
Tethered cord VACTERL Fistulas to GU tract
44
Imperforate Anus Fistulas
High IAs in boys fistulize to bladder or posterior urethra LOW in boys --- perineum High IA in girls - vagina or vestibule Low in girls = perineum
45
Hirschsprung Disease
Affected portion of colon = Small caliber Innervated portion = dilated Dx by Rectal Bx Contrast Enema shows **Rectosigmoid ratio \< 1** or **Sawtooth pattern of rectum** (2/2 spasms)
46
Total Colonic Aganglionosis
Rare variant of Hirschsprung Looks like Microcolon BUT **ALSO AFFECTS THE TERMINAL ILEUM**
47
Obstruction DDx in Older Children
AIM (AA-II-MM) ## Footnote Appendicitis Adhesions Inguinal Hernia (1 month to 1 yo boys) Intussusception (3 months --\> 3 years) Meckel's Diverticulum Midgut Volvulus
48
Small Bowel-Small Bowel Intussusception
\<2-2.5 cm in diameter If length \>3.5 cm --\> Surgery consult bc less likely to resolve spontaneously
49
Meckel's Diverticulum
Persistent Vitelline duct 2% of population 2 types of mucosa = gastric and pancreatic 2 feet from ileum 2 inches long and wide Under 2 yo Dx - Tc-pertechnicate scan (after Pentagastrin, Ranitidine, Glucagon)
50
Complications of Meckel's Diverticulum
GI bleed (gastric mucosa) Diverticulitis (mimics appendicitis) Intussusception Obstruction
51
Midgut volvulus - 3 appearances on Upper GI
1. Duodenum to R of midline (malrotation) 2. Corskscrew duodenum 3. Complete duodenal obstruction (looks like double bubble)
52
Pyloric stenosis
Projectile, bilious vomiting Age 2 weeks - 3 mos \>3 mm thick (hypoechoic part of one wall only) \>14 mm long (or 4 mm and 16 mm) XR = caterpillar sign (gastric contractions) Paradoxical aciduria Ddx = Pylorospasm
53
Gastric Volvulus Types
**Organoaxial** - greater curvature flips over lesser along long axis (**OLD** ladies with paraesophageal hernias) **Mesenteroaxial** - Stomach twists over mesentery (short axis), antrum flips near GE junction--\> can cause ischemia and obstruction **(KIDS)**
54
Duodenal Web
Bilious vomiting Double Bubble in neonate Windsock Deformity on Fluoro Assoc with Downs Syndrome
55
Cause of Annular Pancreas
failure of ventral bud to make full rotation with duodenum --\> encasement of duodenum Circumferential narrowing of duodenum on Fluoro
56
Meconium Peritonitis
Sterile peritoneal reaction to bowel perf in utero Results from atresia or meconium ileus CALCIFIED MASS IN MID ABDOMEN on AXR Can reult in adhesions or psuedocysts --\> obstructions
57
Enteric Duplication Cyst - locations - Rads findings - Associations - DDx
Ileial region, esophagus, and duodenum 50+% contain gastric or panc tissue US - cyst in abdomen with **alternating bands of hyper and hypoechoic signa**l --\> diff layers of bowel (**gut signature)** Without gut signature --\> Omental Cyst (DDx) Assoc with **vertebral anomalies**
58
Cause of distal ileal obstruction in older kids
CF kids not taking pancreatic meds --\> thick stools AKA "grown up meconium ileus"
59
Necrotizing Enterocolitis Risk Factors
Occurs in preemies and kids with heart problems First 10 days of life low birth weight perinatal asphyxia Hirschsprung Hyperosmolar feeds UACs (thrombosis risk) Breast milk - decreases risk
60
NEC imaging findings
Pneumatosis, PV gas Focal, fixed dilated (tubular) loops of bowel (esp RLQ because TI and cecum most affected) Featureless bowel with separation (edema) Unchanging BG pattern over several days (TESTED)
61
Gastroschisis
RIGHT Paraumbilical defect NO surrounding membrane NO assoc. anomalies Elevated maternal AFP (more than omphalocele) Reflux after repair
62
Omphalocele
THROUGH umbilicus, midline Has on membrane **O**ver it Assoc with **O**ther abnormalities
63
Omphalocele Associations
Trisomy 18, Turner's, Klinefelter, Beckwith-Wiedemann Cardiac (50%) Other GI CNS GU Umbilical cord cyst Allantoic cysts
64
Physiologic Gut Herniation
Normal Occurs at 6-8 weeks in utero during organogensis bowel herniates out through umbilicus to grow outside abd cavity (grows faster than abd cavity) **270** degree COUNTERclockwise rotation when going back in Can only dx as abn in 2nd/3rd Tri If contains **LIVER-- always abnormal, even in 1st Tri**
65
Small Left Colon
aka Meconium Plug Syndrome Narrowed distal colon with more proximally dilated loops Preemies Mothers got MagSulfate Mothers with DM Tx - contrast enema
66
Amyand hernia
appendix through inguinal canal
67
Richter hernia
One wall of Sm. Bowel protrudes
68
Spigelian Hernia
Lateral wall hernia along semilunar line lateral to Rectus Abdominis
69
Mesenteric Adenitis
Viral, inflammatory self limiting Cluster of large RLQ LNs on US Mimics appendicitis
70
Pediatric Liver Tumor DDx
Age 0-3 yo 1. Infantile Hemangioendothelioma 2. Hepatoblastoma 3. Mesenchymal Hamartoma Age \> 5 yo 1. HCC (kids with biliary atresia, Fanconi, Glycogen storage), elevated AFP 1. Fibrolamellar HCC - patients under 25, no cirrhosis 1. Central scar is T2 dark unlike FNH 2. Undifferentiated Ebryonal Sarcoma Any age 1. Mets from Wilm's or Neuroblastoma 2. Normal things- hepatic adenoma, hemagiomas, FNH, Angiosarcoma
71
Infantile Hemangioendothelioma
Under 1 yo Assoc. High output cardiac failure CXR- large heart + liver mass * Single large mass OR Multifocal OR diffuse * Peripheral enhancement on arterial, progressive fill in (technically hemangiomas) * **Celiac artery dilated** more than infraceliac aorta Tx- propanolol (like any hemangioma) Most **involute spontaneously as they calcify**
72
Infantile hemangioendothelioma Associations
**Kasabach Merritt Syndtome** (hemangioendothelioma eats up platelets --\> **bleeding and bruising)** 50% have skin hemangiomas VEGF may be elevated
73
Hepatoblastoma
Under 5 yo Painless RUQ mass + Distension (+/- jaundice) Well circumscribed solitary mass - often Right hepatic lobe * US - hypo/isoechoic mass with SPOKE WHEEL appearance (fibrous septa +/- chunky calcs) May extend into PVs, HVs and IVC 50% have calcifications * Mets to lung (doesn't r/o surgery) * Sensitive to chemo
74
Hepatoblastoma associations
* Beckwith-Weidemann * (hemihypertrophy, big tongue, enl. liver/spleen, cardiac abn's, omphalocele, otic dysplasia, neonatal hypoglycemia, facial nevus flammeus) * Wilm's tumor
75
Mesenchymal Hamartoma Features
Predominantly cystic (can be multiple cysts) Developmental anomaly AFP normal Calc's are rare Large PV feeding branch Small risk of malignant degen so surgically remove
76
Types of Choledocal cysts (Todani)
* Type 1 * focal CBD dilatiaton * Type 2 * Saccular outpouching off CBD * Type 3 * Choledococele (at ampulla) * Type 4 * Intra and extrahepatic * Type 5 (Caroli) * Intrahepatic only
77
Presentation of Choledocal cyst
Young Recurrent abdominal pain +/- weight loss +/- fever
78
Caroli Disease
Intrahepatic ductal dilation - large and saccular **Central Dot Sign** = PV surrounded by dilated ducts Cysts connect with biliary system
79
Associations of Caroli Disease
PCKD Medullary Sponge kidney
80
Osler-Weber-Rendu
HHT Hereditary Hemorrhagic Telangiectasia Multiple AVMs in liver and lung leads to cirrhosis and dilated hepatic artery Lung AVMs--\> brain abscesses Lung AVM treated when afferent vessel \>3mm
81
Biliary Atresia
Prolonged jaundice \>2 weeks Abnormal or absent GB, can get gallstones Cirrhosis if not treated Kasai procedures before 3 months old Absence of extrahepatic biliary system
82
Biliary Atresia on Imaging
Triangle.Echogenic cord sign - triangular or linear echogenic structure in front of PV = hepatic duct remnant \*\*Do cholangiogram and bx to confirm (r/o Alagille Syndrtome) HIDA scan -- give phenobarb for 5 days before 99m-Tc-IDA
83
Biliary Atresia associations
Polysplenia Trisomy 18
84
Alagille Syndrome
hereditary cholestasis from no intrahepatic ducts Peripheral Pulm Artery stenosis Absence of intra AND extra hepatic ducts
85
ARPKD
Cysts in kidney Fibrosis in liver - usually worse if kidneys are less cystic (and vice versa) Initial XR- wide abdomn
86
Schwachman-Diamons Syndrome (SDS)
Pancreatic insufficiency (2nd most common cause after CF) Short stature (S) Diarrhea (D) Eczema (S = skin) Lipomatous pseudohypertrophy of pancreas
87
Dorsal Pancreatic Agenesis
Dorsal bud of pancreas doesn't form --\> no tail Ventral bud only --\> head Increased risk of DM because most beta cells are in tail Assoc with POLYSPLENIA
88
Pediatric Pancreatic Masses
Age 1 - Pancreatoblastoma Age 6 = Adenocarcinoma Age 15 -Solid pseudopapillary tumor of Panc
89
Pancreatoblastoma
Primary DDx in patient under 10 Beckwith Wiedemann increases risk Large + calcifications + vessel encasement Liver mets
90
Situs Inversus Organ locations
Liver on L Stomach on R Minor fissure on L **Inverted** bronchial pattern - airways run ABOVE the PAs (eparterial) except RUL bronchus where it is below (hyparterial) Assoc with Primary Ciliary Dyskinesia
91
Situs Ambiguus with Right Isomerism
Bilateral minor fissures Absent spleen Strong assoc with Cyanotic heart disease
92
Situs Ambiguus with Left Isomerism
Absent minor fissues Interrupted IVC Polysplenia Assoc with Biliary Atresia in 10%
93
Turner's Syndrome Features/Associations
Cystic Hygroma Aortic Coarctation Bicuspid Ao valve Horseshoe kidney Short 4th metacarpals IUGR Hydrops fetalis Short fetal limbs

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